Chapter 21 Abdomen

Four layers of large, flat muscles form the ventral abdominal wall. These are joined at the midline by a tendinous seam, the Linea Alba. Inside the abdominal cavity, all the internal organs are called the viscera. Solid Viscera - are those that maintain a characteristic shape (liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus). Hollow Viscera these depend on the contents (stomach, gal bladder, small intestine, colon, and bladder). The twelfth rib forms an angle with the vertebral column, the costovertebral angle. The left kidney lies here at the !!th and !"th ribs. #ecause of the placement of the liver, the right kidney rest ! to " cm lower than the left kidney and sometimes may be palpable. The abdominal wall is divided into four $uadrants% Epigastric the area between the coastal margins. mbilical & the area around the umbilicus. H!pogastric or S"prap"bic the area above the pubic bone. 1,FT *++,' -*./'.0T (1*-) 6tomach 6pleen 1eft 1obe of 1iver #ody of +ancreas 1eft 2idney and .drenal 6plenic Fle4ure of 5olon +art of Transverse and /escending 5olon 1,FT 178,' -*./'.0T (11-) +art of /escending 5olon 6igmoid 5olon 1eft 7vary and Tube 1eft *reter 1eft 6permatic 5ord 'I()T *++,' -*./'.0T ('*-) 1iver (all #ladder /uodenum )ead of +ancreas 'ight 2idney 3 .drenal )epatic Fle4ure of 5olon +art of .scending and Transverse 5olon 'I()T 178,' -*./'.0T ('1-) 5ecum .ppendi4 'ight 7vary and Tube 'ight *reter 'ight 6permatic 5ord 9I/1I0, .orta *retus (if enlarged) #ladder (if distended)

#he Aging Ad"lt .ging alters the appearance of the abdominal wall area. /uring after middle age, some fat accumulates in the suprapubic area in females as a result of decreased estrogen levels. 9ales also show some fat deposits in the abdominal area, resulting in the :big belly;. 6alivation decreases, causing a dry mouth and a decrease sense of taste. ,sophageal emptying is delayed. If an aging person is fed in the supine position, this increases the risk for aspiration. (astric acid secretion decreases with aging. This may cause pernicious anemia (because it interferes with vitamin #!" absorption), iron deficiency anemia, and malabsorption of calcium. The incidence of gallstones increases with age, occurring in !<= to "<= of middle aged and older adults, being more common in females. 1iver si>e decreases by "?= between the ages of "< and @< years, although most liver function remains normal. /rug metabolism by the liver is impaired, in part because age A? blood flow through the liver is decreased by BB=. Therefore the liver metabolism that is responsible for the en>ymatic o4idation, reduction, and hydrolysis of drugs is substantially decreased with age. +rolonged liver metabolism causes increased side effects (e4ample, older people taking ben>odia>epines scored lower on functional status measures and had increased risk for hip fracture.) .ging persons fre$uently report constipationC most prevalence estimates are between !"= and !D=. #ecause there is confusion as to what defines constipation, the 'ome criteria have developed a standardi>ed symptom criteria. These symptoms include reduced still fre$uency (less than three bowel movements per week), as well as other common and troubling associated symptoms (i.e. straining, lumpy or hard stool, feeling of incomplete evacuation, feeling of anorectal blockage, use of manual maneuvers. 5ommon causes of constipation include decreased physical activity, inade$uate intake of water, a low fiber diet, side effects of medications (opiates, tricyclic antidepressants), irritable bowel syndrome, bowel obstruction, hypothyroidism, and inade$uate toilet facilities (i.e. difficulty ambulating to the toilet may cause the person to deliberately retain the stool until it becomes hard and difficult to pass. C"lt"re And $enetics 1actase is the digestive en>yme necessary for absorption of the carbohydrate lactose (milk sugar). In some racial groups, lactase activity is high at birth but declines to low levels by adulthood. These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed. 9illions of .merican adults have the potential for lactose intolerance symptoms and traditional estimated rates were that ?<= of whites, ?<= of 9e4ican .mericans, and E<= of .frican .mericans had the condition. This is clinically significant because dairy foods meet crucial nutritional re$uirements including calcium, magnesium, and potassium. %besit! is the accumulation of e4cess body fat. 7besity is caused by a comple4 interaction of genetic predisposition, dietary intake, physical inactivity, and what is now called &obesogenic environment' (one that encourages large populations of high fat, energy dense foods). .mong the children, 9e4ican .merican boys had a greater prevalence of overweight than had white or black boys. 9e4ican .merican and black girls were significantly more likely to be overweight than white girls. 0o differences were found in overweight rates in men of various racial groups. #ut in adult woman, 9e4ican .mericans and .frican .mericans were significantly more likely to be obese than were whites. 7besity in adults results in comorbidities of type II diabetes and cardiovascular disease. 7bese children have an increased risk for asthma, diabetes, liver disease, cardiovascular disease, sleep apnea, and joint problems, and they risk becoming obese adults.

Anore(ia is a loss of appetite from gastrointestinal disease, as a side effect of some medications with pregnancy or with psychological disorders. )!sphasia occurs with disorders of the throat or esophagus. *ood intolerance (e.g. lactase deficiency resulting in bloating or e4cessive gas after taking milk products). +!rosis (heartburn), a burning sensation in the esophagus and stomach, from reflu4 of gastric acid. Abdominal pain may be visceral from an internal organ (dull, general, poorly locali>ed)C parietal from inflammation of overlying peritoneum (sharp, precisely locali>ed, aggravated by movement)C or referred from a disorder in another site. .cute pain re$uiring urgent diagnosis occurs with appendicitis, cholecystitis, bowel obstruction, or a perforated organ. ,a"sea-vomiting is common with (.I. disease, many medications, and with early pregnancy. Hematemisis (coffee grind material, bleeding) occurs with stomach or duodenal ulcers and esophageal varices. .ssess usual bowel habits. .lac/ stools may be tarry due to occult blood (melena) from (.I. bleeding or non tarry from iron medications. $ra! stools occur with hepatitis. How do !o" ac0"ire !o"r groceries and prepare !o"r meals assess risk for nutritional deficit% limited access the grocery store, income, or cooking facilitiesC physical disability (impaired vision, decreased mobility, decreased strength, and neurologic deficit). Food pattern may differ during the month if monthly income (e.g. 6ocial , 6ecurity check) runs out. S/in 7ne common pigment change is striae (leneae albicantes) silver! white, linear, jagged marks about ! to A cm long. They occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching, as in pregnancy or a lot of weight gain. 1ecent striae are pin/ or bl"e then the! t"rn silver! white. +"lsation or movement 9arked pulsation of aorta occurs with widened pulse pressure (e.g. hypertension, aortic insufficiency, thyroto4icosis) and with aortic aneurysm. Abdominal Assessment - 2nspect3 A"sc"ltate3 +erc"ss3 +alpate. s"al Assessment - 2nspect3 +alpate3 +erc"ss3 A"sc"ltate. A"sc"ltate .owel So"nds 4 Vasc"lar So"nds /epart from the usual e4amination se$uence and auscultate the abdomen ne4t. This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. *se the diaphragm endpiece because bowel sounds are relatively high pitched. )old the stethoscope lightly against the skinC pushing too hard may stimulate more bowel sounds. #egin in the '1- at the ileocecal valve area because bowel sounds are normally always present here. .owel So"nds 0ote the character and fre$uency of bowel sounds. #owel sounds originate from the movement of air and fluid through the small intestine. /epending on the time elapsed since eating, a wide range of normal sounds can occur. #owel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from ? to B< times per minute. /o not bother to count them. 5"dge i6 the! are normal3 h!poactive3 or h!peractive. 7ne type of hyperactive bowel sounds is fairly common. This is the hyper peristalsis when you feel your :stomach growling; termed borbor!gm"s. . perfectly :silent abdomen; is uncommonC !o" m"st listen 6or 6ive min"tes by your watch be6ore deciding bowel so"nds are completel! absent. 1. H!peractive so"nds are loud, high pitched, rushing, tinkling sounds that signal increased motility 2. H!poactive or Absence So"nds follow abdominal surgery or with inflammation of the peritoneum.

Vasc"lar So"nds .s you listen to the abdomen, note the presence of any vascular sounds or bruits. *sing firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension. *sually, no such sound is present. )owever, a small number of healthy persons (usually younger than F< years) may have a normal bruit originating from the celiac artery. This is systolic, medium to low in pitch, and heard between the 4iphoid process and umbilicus. $eneral #!mpan! First, percuss lightly in all four $uadrants to determine the prevailing amount of tympany and dullness. 9ove clockwise. #!mpan! sho"ld predominate because air in the intestines rises to the surface when the person is supine - Dullness occurs over a distended bladder, adipose tissue, fluid, or a mess. Hyperresonance is present with gaseous distention. Liver Span 0ormal liver span in the adult ranges from A to !" cm&an enlarged liver span indicates big liver (Hepatomegaly) Splenic )"llness 7ften the spleen is obscured by stomach contents, but you may locate it by percussing for a dull note from the 7th to 11th intercostal space just behind the left mida4illary line. The area of splenic dullness normally is not wider than @ cm in the adult and should not encroach on the normal tympany over the gastric air bubble - a dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis, trauma, and infection. Costovertebral Angle #enderness To assess the kidney, place one hand over the !"th rib at the costovertebral angle on the back. Thump that hand with the ulnar edge of your other fist sharp pain occurs with inflammation of the idney or paranephric area. Special +roced"res .t times, you may suspect that a person has ascites (free fluid in the peritoneal cavity) because of a distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward !scites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. Gou can di66erentiate ascites from gaseous distention by performing two perc"ssion tests. 1. *l"id 8ave First, test for a fluid wave by standing on the personHs right side. +lace the ulnar edge of another e4aminers hand or the patientHs own hand firmly on the abdomen in the midline (this will stop transmission across the skin of the upcoming tap). +lace your left hand on the personHs right flank. 8ith your right hand, reach across the abdomen and give the left flank a firm strike & "f ascites is present, the blow will generate a fluid wave through the abdomen and you will feel a distinct tap on your left-hand. "f the abdomen is distended from gas or adipose tissue, you will feel no change. 2. Shi6ting )"llness In a supine person, ascetic fluid settles by gravity into the flanks, displacing the air filled bowel upward. Gou will hear a tympanitic note as you percuss over the top of the abdomen because gas filled intestines float over the fluid. Then percuss down the side of the abdomen. If fluid is present, the note will change from tympany to dull as you reach its level. 9ark this spot. 0ow turn the person onto the right side. The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward. #egin percussing the upper side of the of the abdomen and move downward. The sound changes from tympany to a dull sound as you reach the fluid level, but this time the level of dullness is higher upward toward with the umbilicus. This shifting level of dullness indicates the presence of fluid #hifting Dullness is positive with a large volume of ascitic fluid$ it will not detect less than %&& m' of fluid.

+alpate S"r6ace And )eep Areas +erform palpation to judge the si>e, location, and consistency of certain organs and to screen for an abnormal mass or tenderness. Light And )eep +alpation #egin with light palpation. 8ith the first four fingers close together, depress the s/in abo"t 1 cm. Ioluntary guarding occurs when the person is cold, tense or ticklish. It is bilateral, and you will feel the muscles rela4 slightly during e4halation. *se the rela4ation measures to try to eliminate this type of guarding, or it will interfere with deep palpation. If the rigidity persists, it is probably involuntary involuntary rigidity is a constant, board li e hardness of the muscles. "t is a protective mechanism accompanying acute inflammation of the peritoneum. "t may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit up. 0ow perform deep palpation using the same techni$ue described above but this time down push down abo"t 9 to : cm and move clockwise to e4plore the area. ,ormal *indings ;ild tenderness normall! is present when palpating the sigmoid colon . .ny other tenderness should be investigated. If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following% !. 1ocation (enderness occurs with local inflammation, ". 6i>e with inflammation of the peritoneum, or B. 6hape underlying organ, and with an enlarged F. 5onsistency (6oft, Firm, )ard) organ whose capsule is stretched. ?. 6ervice (6now, 0odular) A. 9obility (Including 9ovement 8ith 'espirations) @. +ulsatility E. Tenderness Liver .sk the person to breathe slowly. 8ith every e4halation, move your palpating hand up ! or " cm. It is normal to feel the edge of the liver. #ump your fingertips as the diaphragm pushes it down during inhalation. It feels like a firm, regular ridge. 7ften, the liver is not palpable and you feel nothing firm. Spleen 0ormally, spleen is not palpable and must be enlarged three times its normal si>e to be felt the spleen enlarges with mononucleosis, trauma, leu emias, and lymphomas. "f you feel an enlarged spleen (spleenomegaly), refer the person but do not continue to palpate it. !n enlarged spleen is friable and can the rupture easily with overpalpation. <idne!s 6earch for the right kidney by placing your hands together in a :duck bill; position at the personHs right flank. +ress your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask the person to take a deep breath. In most cases you will feel no change. The left kidney sits ! cm higher than the right kidney and is not palpable normally. Aorta *sing your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of the midline. 0ormally, it is ".? to Fcm wide in the adult and pulsates in an anterior direction.

Special +roced"res 6or Advanced +ractice 1ebo"nd #enderness =.l"mberg Sign> assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. 5hoose a site away from the painful area. )old your hand D<J, or perpendicular, to the abdomen. +ush down slowly and deeply then lift up $uickly. . normal, or negative, response is no pain on release of pressure. +erform this test at the end of the e4amination, because it can cause severe pain and muscle rigidity pain on release o6 press"re con6irms rebo"nd tenderness3 which is a reliable sign o6 peritoneal in6lammation. +eritoneal in6lammation accompanies appendicitis 2nspirator! Arrest =;"rph! Sign> normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder (cholecystitis), pain occurs. )old your fingers under the liver border. .sk the person to take a deep breath. . normal response is to complete the deep breath without pain. (0ote% this sign is less accurate in patients older than A< yearsC evidence shows that "?= of them do not have any abdominal tenderness.) 8hen the test is positive3 as the descending liver p"shes the in6lamed gallbladder onto the e(amining hand3 the person 6eels sharp pain and abr"ptl! stops inspiration midwa!. 2liopsoas ;"scle #est perform the iliopsoas muscle test when the acute abdominal pain of appendicitis is suspected. 8ith the person supine, lift the right leg straight up, fle4ing at the hip, then push down over the lower part of the right thigh as the person tries to )old the leg up. 8hen the test is negative, the person feels no change when the iliopsoas muscle is inflamed (which occurs within an inflamed or perforated appendi4), pain is felt in the right lower $uadrant. Common Sites %6 +re6erred Abdominal +ain )"oden"m /uodenal ulcer typically has dull, Esophag"s &&(astroesophageal reflu4 disease aching, gnawing pain, does not radiate, may be ((,'/) is a comple4 of symptoms of esophagitis, relieved by food, and may awaken the person from including burning pain in midepigastrium or behind sleep. lower sternum that radiates upward, or :heartburn.; 7ccurs B< to A< minutes after eatingC aggravated by Stomach (astric ulcer pain is dull, aching, lying down&or bending over. gnawing epigastric pain, usually brought on by food, radiates & to5holecystitis back or substernal area. +ainsudden of $allbladder is biliary colic, perforated ulcer is burning epigastric pain of sudden pain in right upper $uadrant that may radiate to onset that refers to one orwhich both shoulders. right or left scapula, and builds over time, lasting " to F hours, after ingestion of fatty foods, Appendi( & typically starts as with dull,nausea diffuseand pain in alcohol, or caffeine. .ssociated periumbilical region that later shifts to severe, vomiting and with a positive 9urphy sign or a sharp, pain and tenderness suddenpersistent stop in inspiration with '*- locali>ed palpation.in '1- (9c#urney point). +ain is aggravated by movement, coughing the, deep breathingC associated with anore4ia, then nausea and vomiting, fever.